June 11, 2009

"The A.M.A. does not believe that creating a public health insurance option for non-disabled individuals under age 65 is the best way to expand health insurance coverage and lower costs. The introduction of a new public plan threatens to restrict patient choice by driving out private insurers, which currently provide coverage for nearly 70 percent of Americans."

If private insurers are pushed out of the market, the group said, "the corresponding surge in public plan participation would likely lead to an explosion of costs that would need to be absorbed by taxpayers."...

The medical association said it “cannot support any plan design that mandates physician participation.” For one thing, it said, “many physicians and providers may not have the capability to accept the influx of new patients that could result from such a mandate.”

JAMA, The New England Journal, the Society of General Internal Medicine, and the American College of Physicians have all proposed or agreed to socialism as the preferred ordering mechanism for health care. That has been the case for more than a decade.

All current intellectual thought in medicine and politics is along these lines. The AMA might as well announce against global warning.

Me? Well, as soon as physicians are mandated into government employ, I'll do what every physician in every socialist country that doesn't shoot its own citizens has done: unionize, then strike.

Medicare and Medicaid are run by the government. How's that working out?

I understand that many lefties will knee-jerk reflexively and parrot everything that comes from the White House and Left-wing Dems on healthcare without so much as 20 minutes of thinking the issue through.

But when you consider the state of Medicare and Medicaid today, that should scare people shitless and give pause before going forward with such obviously poorly thought out government prescriptions. We are already on the way because of Obama's deficit to an inevitable period of inflation - and fast. Why should we allow someone's good intentions - that's all they are at this point - guarantee an even greater economic fucking of the nation?

The belief that doctors are "profiting from people being sick" is like saying grocers are profiting from people being hungry, carpenters are profiting from people being homeless, clothiers are profiting from people being naked, and opticians are profiting from people being nearsighted.

Well, yes they are.

Would it be better that doctors were profiting from people being healthy?No.

In socialism, the discomfort is over the word profit, which is evil because it invokes the ideas of liberty and private property.

Right now, Medicare patients are unable to find doctors who will take them, because many MDs cap their Medicare exposure at 20% of the entire practice. I see people who fly in from 3 states away looking for a 'primary' doctor.

So the answer to health care costs under Obama is to force doctors to take a massive pay cut, so that all we are paid is what paltry sum Medicare offers.

Insurance companies are not on the side of medical cost saving, despite first impressions.

They make money paying out all the premiums they take in, from the investment returns in the meantime.

If medical costs rise, they raise premiums to cover it, but make more money on the investment in the meantime; in addition, the higher costs give them more customers as some who had been self-insuring can no longer afford the risk and start buying insurance.

Higher medical costs are good for them.

Doctors make money on the increased costs, except they're also deep pocket scapegoats, so are likely to change sides depending on the winds.

All current incentives, because of insurance, have tilted doctors toward endlessly rasing costs.

Medicare chose price fixing as their mechanism to hold down costs, but it merely shifted the costs onto commercial insurance, raising its fees even higher to subsidize the elderly.

By taking over the whole game the government can set the prices for everything, but price fixing does not fix the costs.

That, of course, is one of the fundamental errors in socialist thought that dooms it to failure.

But shit, who am I kidding?I have two choices:1) Comply and then strike. And strike repeatedly (hey, it worked for Canadian MDs).2) Leave the country. But where can MDs practice free? China? France? The Middle East?

Medicare and Medicaid isn't as bad overall, IMO, as the true government run health care plan - the VA hospital system. Lets have the Congress and the White House (including all their staff and families) be forced to purely use the VA hospital system (no using Bethesda Naval as some can now) for two years. God, I hope they don't have any relatives (or themselves) are suffering from mental illness - my family's experience with VA coverage (an area that I conceptually think they should focus on and be great at considering the source and experience of their customers) in that area was horrible.

The damage done to us in the last 3 months of socialism planning exceeds the good done for us in the last 30 years by the free market system. The whole USA is becoming one big Scapegoat being abandoned to die while Washington throws itself a great awards banquet.No wonder the biggest worry in DC is whether American citizens will meekly comply and die or try to fight back.

If you believe that insurance companies aren't doing a great job for you, what in God's name makes you think that government will do a better job?.

Well the problem is that most people that think of universal health care isn’t that the government is going to run health care but simply pay for it. The idea is out there that you just zip on down to your PCP or hospital for whatever care you need, show your universal health care card and that’s it.

The problem with health insurance is that it isn’t treated as insurance like life or property and casualty insurance. You don’t file a claim with your car insurance for your oil changes, tire rotations or tune ups. You don’t file (or should not) file a claim for basic home maintenance like replacing the furnace, air condition, water heater, re-roofing. With health insurance people expect to pay a $10 or $20 co-pay every time they walk into the physician’s office and that’s it. If auto or homeowner's insurance worked in the same manner as health insurance, they would be unaffordable.

If Medicare or private health insurance scaled back to simply providing catastrophic care and left the basic ‘maintenance’ up to the consumer, you’d see insurance costs plummet and probably physician costs come down as well. But they won't because most people refuse to pay for care that they 'expect' a third party to cover.

"Phil Donohue: When you see around the globe the maldistribution of wealth, the desperate plight of millions of people in underdeveloped countries. When you see so few haves and so many have-nots. When you see the greed and the concentration of power. Did you ever have a moment of doubt about capitalism? And whether greed is a good idea to run on?

Milton Friedman: Well first of all tell me, is there some society you know that doesn’t run on greed? You think Russia doesn’t run on greed? You think China doesn’t run on greed? What is greed? Of course none of us are greedy. It’s only the other fella that’s greedy. The world runs on individuals pursuing their separate interests. The greatest achievements of civilization have not come from government bureaus. Einstein didn’t construct his theory under order from a bureaucrat. Henry Ford didn’t revolutionize the automobile industry that way. In the only cases in which the masses have escaped from the kind of grinding poverty that you are talking about, the only cases in recorded history are where they have had capitalism and largely free trade. If you want to know where the masses are worst off, it’s exactly in the kind of societies that depart from that.

So that the record of history is absolutely crystal clear, there is no alternative way, so far discovered, of improving the lot of the ordinary people that can hold a candle to the productive activities that are unleashed by a free enterprise system.

Phil Donohue: Seems to reward not virtue as much as the ability to manipulate the system.

Milton Friedman: And what does reward virtue? You think the Communist commissar rewards virtue? You think a Hitler rewards virtue? Do you think… American presidents reward virtue? Do they choose their appointees on the basis of the virtue of the people appointed or on the basis of political clout? Is it really true that political self-interest is nobler somehow than economic self-interest? You know I think you are taking a lot of things for granted. And just tell me where in the world you find these angels that are going to organize society for us? Well, I don’t even trust you to do that."

Pogo speaks the truth. Physicians and hospitals now lose money every time they see a Medicare patient because Medicare does not pay the cost of the visit/hospital stay. Should government take control of the medical industry, doctors will simply find another line of work. No one can afford to work for no pay. How can a physician afford to work for negative pay?

"paul a'barge said... I'd be all up in a dither about this if doctors were not heavily invested in profiting from people being sick.

Unlike dentistry which for years has been invested in helping people maintain the good health of their teeth, doctors have never really dedicated themselves to our health.

If you doubt this, ask people who try to expense their chiropractic or acupuncture treatments on their health insurance."

Bullshit. You are full of it. If this is true, explain why my doctor and past doctors have put me on:

1. Excercise and diet regimen to get me off of the statins and fibrates.2. Allergy shots to get me off of antihistamines3. Excercise and diet regimen to get my blood glucose levels under control so I can stop taking diabetes med (Glipizide)

If they were indeed profit motivated, why the hell are they trying to get me to the point where I'm only seeing them for routine checkups? And why the hell are they trying to get me off of supposedly "profitable" meds? Because if I'm not coming in for anything above and beyond routine checkups, I'm not paying them for anything but those checkups. Yet those regimens were designed to do exactly that.

There's plenty to legitimately criticize about modern medicine, but what you said ain't it. Get your facts straight.

We'll have to wait and see how other medical organizations respond, but this sounds like another major Obamafail. He's supposed to be the type of President who consults with everyone before he comes up with policy decisions. If the doctors are against his plan (who have been calling for socialized medicine as a group) it must be seriously flawed.

I owe my life to a team of excellent specialists--and their skill and diligence has made me "lucky" in detecting three primary cancers early before they got dangerous--and I'm having surgery tomorrow and will find out about a potential fourth primary cancer.

I know how hard they work. They work extra long days every day. They have called me on Sundays from their office. They come in on their own medical leave to look after me.

And they give up a lot up front in the prime of their life--all that schooling, the pressure, the no or low income. They make sacrifices.

I just hate when people envy and tear down doctors and their higher social status and their higher incomes. They look at gross income and not net--doctors have overhead! Liability insurance, building, utilities, staff, equipment, supplies, CME, the costs associated with medical insurance billing and coding itself.

I do not envy doctors their earnings and status. They deserve it.

And a lot of them are very charitable--providing pro bono medical care in charity clinics and events like RAM (Remote Area Medical--happens here about every year) and medical missions abroad and Doctors Without Borders.

Doctors are often not money obsessed because they work too hard to have enough time to sit around and obsess about money. Doctors are often prime pickings for insurance scammers, I mean agents, and investment gurus and coaches who are happy to profit off their income.

I don't know why dentists are considered to be so noble. They are dentists because they weren't sharp enough to get into med school, and/or they wanted the high income without the stress of being an MD, and to keep their evenings and weekends free. No on call overnights and weekends. The path of least resistance. Not so noble.

I have deep, sincere gratitude towards the docs in my life. I fear a system that would drive them out of the business or the country. My life might be at stake here.

The doc who is doing the surgery tomorrow recently apologized to me for being on vacation (when I was trying to get FML forms completed)--I told her, no worries, I'd rather have a happy, relaxed, well-rested doctor coming at me with a knife. Enjoy your vacation!

(Which she must be taking locally because she's in town?! And has a couple of surgery dates scheduled during her vacation?!)

I fear the gummint bureaucrats will deny me more treatment if I have another primary cancer, or a recurrence, or mets. They'll say too bad, you've used up your fair share and we're cutting you off. Even if my fair share was what I paid for with private insurance and out of my pocket. Remember, The Big O is all about what is fair to the downtrodden. I've had too much high quality care for years now. Time to share the wealth. Even if it brings about my untimely death. *sigh*

I think part of it is the family wanting the sick person to stay alive. My impression sometimes is that a doctor thinks he has failed when a patient dies. (Pogo, is my impression right?) Those two things drive up end-of-life care costs.

My recent experience with a family member dying was different. Most of the end-of-life care was palliative. Could he have lived a year or two more? Well, maybe, but the cost would have been enormous.

Someone might say that we (well, the wife's family) got to make that choice, not the Government. True. But the way things are set up, the cost of prolonging a life is hidden from the family.

Jason, doctors are not against the plan. Most doctors are socialists now. People I work with are for it, and sit on some of the big medical organizations I named above.

Free ice cream seems hard to pass up.

US doctors support universal health care - surveyReutersMon Mar 31, 2008"More than half of U.S. doctors now favor switching to a national health care plan and fewer than a third oppose the idea, according to a survey published on Monday.

Of more than 2,000 doctors surveyed, 59 percent said they support legislation to establish a national health insurance program, while 32 percent said they opposed it, researchers reported in the journal Annals of Internal Medicine."

If we get gummint care, double-check your living will or advanced directives document. If you used the boilerplate form the hospital gave you, it contains language totally handing over care decisions to the hospital and the doctor.

Instead, use a Health Care Power of Attorney document to restrict medical decision making to your designee. This can be combined with a Protective Medical Decisions Document where you can lay out some terms and conditions. Mine says you can't deny nutrition or hydration. My sister is my HCPOA and she knows my morals and ethics and medical thinking. I trust her...more than any faceless bureaucrat or hospital administrator who doesn't know me.

State specific forms are available (cheap!) from:http://www.internationaltaskforce.org/

Drill Sgt is right. Don't hand over your care decisions to people who are primarily concerned about fixed budgets and cost containment.

Like Oregon--state gummint health care + physician assisted suicide is legal, and you get situations like the one where the woman with recurrent cancer was denied treatment (oral chemo--pill form), and in the same letter, she was encouraged to check out PAS as a solution to her problem.

Most MDs recognize the mortality rate for all of us is 100%. They are most aggressive if they think the timing of death can be forestalled, if the suffering is not too great. But they accept the inevitable, and try to avoid adding to the burden of unavoidable demise. They often accede to the wishes of the patient in either case, where prolongation is demanded in the face of futility, or if their choice is to chuck it all sooner than would seem warranted.

Doctors have a wide range of comfort in this area. And on both extremes are MD assholes who are thieves, cowboys, demigods, or nihilists.

:I'd be all up in a dither about this if doctors were not heavily invested in profiting from people being sick."

Actually they profit from making people un-sick. But if you don't like the doctor's self-interest as a motivator, what would you like to try? Altruism is a very unreliable emotion, so the next step away from the profit motive is to use coercion. Oh yes, that will inspire people to go to work every day!

Also, I see the AMA does support "affordable" health insurance. If they read Hoosier's advice, they could get there. But you can't make it affordable when you mandate chiro, mental health, acupncture, etc and etc.

Lastly, how do you agree on what is affordable? I never hear politicians talk much about the cost of cell phones, or cable TV or cigarettes or booze or internet service or Starbucks coffee but many many Amercians seem to be able to afford those "necessities".

"The AMA represents the interests of medical doctors and, of course, medical doctors don’t really have a big interest in making health care more efficient. After all, what looks like inefficiency to health care wonks looks like “income” to doctors. Defense contractors don’t like procurement reform, and when school systems try to reform their labor practices to better reward quality teaching, teacher’s unions tend to oppose it. Such is life. Incumbent stakeholders don’t like change, but when you have an inefficient system — like health care in the United States — it’s often very helpful to push change that incumbent stakeholders don’t like."

I have to say the doctor we interacted with was stellar, absolutely a gem. She knew exactly what we wanted and tailored care to those wants, and did reasonable things that we asked -- like an ultrasound after she heard swishing in the abdomen -- just to find out what we're dealing with. I wonder what she would have done if the wife's family had demanded more active intervention. Insurance would have paid for it, I'm sure.

But in the end, Quality of Life should trump all. But Quality means so many different things to different people.

It will be interesting to watch how this plays out in DC. The local Rep, Tammy Baldwin, whom I don't really support with any enthusiasm, has run for Congress many times with Health Care as an agenda. I suspect this might be her undoing, as it will be very very hard to get right, and very easy to screw up.

It's coming. As Pogo notes, a solid majority of physicians now favor a universal system. Employers are for it by even higher margins, noting that the health care funding burden that falls on them cripples our economic competiveness and ability to export. The advanced nations with universal plans have export surpluses, and longer life expectancy....and all have positive export surpluses.

Economists note that paying 50% more than other nations per capita for health services is unsustainable from not only a jobs-competiveness standpoint, but also for preventing our entitlement programs medicaid and medicare from collapsing.

The forces of globalism that have shuttered US factories and destroyed good jobs in favor of outsourcing manufacturing to Cheaper 3rd World labor has introduced a new shock to previously "small government, moderate, independent" Americans. The replacement jobs don't offer adequate health coverage - unless they are in a lower-paying but stable, full benefit GOVERNMENT worker position.

For now, government jobs fueled by massive deficit spending by States, and by the globalists running the country under Clinton, Bush II, and Obama have masked the problem of a country ultimately being unable to afford 1st class medical services with 3rd world labor costs in most productive centers. But that is economically unsustainable - the massive deficits cannot continue - China moneylenders have told us that.

Service jobs ultimately depend on the ability of taxpayers and workers with discretionary income to generate the surplus wealth needed to have doctors, lawyers, Marines, road workers, teachers having only 20 in a class vs. 40 students.

Near-bankrupt California is the future of All America...unless we change our "that's the way we've done things for 40 years!" mentality, drastically and soon.

That means service worker costs have to be lowered - to match what the debased wage of the productive worker in the "global free market" who lives in America can command.

Part of that means getting a medical system that is 50% less costly. And that doesn't mean people being marched to take what the "status quo" forces try to scare us with - that it will be the "Soviet!!" system or even the badly run UK system. We can take the German, French, Japanese, Scandanavian systems they have worked a century on to get the kinks out and running well.

The insurance companies are terrible.A report last fall pointed out that 62% of personal bankruptcies are due to health care costs.

Getting sick should not be a ticket to the poorhouse, yet it is in America today.

I also don't see the rationale for the profit motive in the provision of medical services. Profit-maximizing behavior is not at all compatible with effective health care delivery, as we see all around us.

But the first priority for many in Congress is to protect big business. As we have seen.

What is lost in all of the political and policy wonkism is this; doctors are business people. According to the Party, this legislature, and this administration, business people are evil, greedy, profit whores who must be destroyed at all costs.

First they are going after the auto industry, the oil industry, and the banks. Next they will come after you.

They want to destroy the current American Enterprise System in favor of some utopian collectivist propaganda dream. They care not about the people. They care about the power.

Pointing to the failures and weaknesses of the current health care system, and I am mired deep in them, is no excuse to create this monster. However well intentioned it is supposed to be, it will eventually drive more and more people into the care of the federal government. There is no way that is a good thing.

Yglesias seems to consistently opine that govt workers, including a lifetime bean counter and drone like Peter Orszag, are better qualified to find and cut costs in a very complex industry.

Have you ever been involved in an audit or a business review where your employer brings in some well-paid consulting firm to analyze the company operations? Typically the "consultants" are smart but young, inexperienced dweebs like Yglesias. And the consulting firm makes money but the employees just laugh at the boss for wasting a bundle of money.

Sidebar- here in PA, the state legislature just passed a law that people can keep their kids on their health plan til they are 29 years old!! WTF? I predict Obama's plan will be dumber than that!

The insurance companies are also MORE inefficient and more bureaucratic than the government system! It's the reverse of the stereotype..

Alpha, do us a favor and please do not expound on stuff you have no clue about. I have worked in the insurance industry for well over 15years including health insurance and I can assure you that if private health insurers were as inefficient as the government they'd all be insolvent.

Cford:The "competitive" issue is misleading. Those foreign employers must pay a big payroll tax to their govt to fund the govt health insurance. So I suggest this talking point was extarpolated from the auto industry which screwed itself by giving platinum-plated benefits to American auto workers union.

Alpha:The bankruptcy issue was first reported in a lying study put forth by Elizabeth Warren, a Harvard libtard professor, and current Obama admin consutant. The study counted medical bills as the cause of the bankruptcy if the bills were as low as $1,000. It was a pure bullshit study as was the one that came out last week form Warren's co-author, another Harvard libtard.

Thanks, Pogo, for the condolences. The passing was peaceful, and everyone was there for it, so that was very nice. I liken it to a birth, in that things before/after are very different. Just with a birth, someone's coming and with a death someone's leaving. Symmetric!

Mention was made above about longer life expectancies under nationalized or single payer plans. I would suggest that using gross metrics such as life expectancy or infant mortality are misleading. Why? Because the US is a very heterogenous nation. Comparing the life expectancy of aggregated subgroups against a homogenous nation such as, say, Sweden is a statistical non-starter. You must compare like groups against like groups; eg, mexican americans versus mexicans.

I would suggest a much better measure of health care system efficacy is the survival rate for patients following medical intervention.

If you are interetsted in reading a good journal about the economics of health care (versus health care itself) I recommend the Journal "Health Affairs."

Solutions to the "health care crisis" remind me of HL Mencken's observation: "for every complex problem, there is a solution: neat, simple, and wrong."

It was also pointed out that the major portion of medical costs are run up during the last year of a patient's life. As we epidemiologists are fond of saying, life has a bad outcome. This comes down to a value question, as MM discussed (condolences, MM: how much are we prepared to spend to prolong that bad outcome? Because the outcome has 100 percent certainty. And is that a decision we want the government involved in?

Hoosier, medical "studies" point to low govt. administrative costs in the US (e.g. Medicare), but neglect the fact that the majority of the administrative burden for Medicare is borne by the clinics, hospitals, and insurers.

For Medicare, all that work is compulsory and "free".It's bullshit accounting.

Good review here."Businesses must include management costs in their administrative costs: Medicare doesn’t. The salaries of those professionals at the Centers for Medicare and Medicaid Services (CMS), from Dr. Mark McClellan down, are excluded from Medicare’s administrative cost estimates, as are the building costs to house that part of the leadership team. Private insurers don’t have that luxury.

...the federal government also raises capital and borrows money to pay Medicare claims, and it even pays itself interest on some of that borrowed money. But it includes none of these costs in its administrative estimates; it simply takes (or will take) the money from taxpayers.

...part of Medicare’s “premiumcollection” actually shows up in employers’ administrative costs...rather than Medicare’s. Revenue to pay the government’s share of Part B — 75 percent of the program’s costs — comes from general revenues collected by the IRS. And the SSA collects the 25 percent of the Part B program that comes from seniors’ Social Security checks. Yet again, those “collection costs” are ignored in Medicare administrative cost estimates."

The only downside to Socialism is that it pays no one to work. Therefore no one works. When everybody gets equal care for free, then there is no reason to expect anyone to ever work again. Next step is to rob other societies where people have something left to steal. The final step is to use enslavement by Guns and Whips and Gulag death threats. What a brave new world that The Smile of Obama has promised to give to us.

Here's the basic question everyone should ask themselves before going forward with this so-far poorly thought out plan for government run health care:

If you believe that insurance companies aren't doing a great job for you, what in God's name makes you think that government will do a better job?

The government is not planning to replace insurance companies, merely to provide one more option in the market place.

I would turn chase's question upside down: If you believe insurance companies are doing a great job for you, what in God's name makes you think that government will do a better job?

Medicare and Medicaid are run by the government

Medicaid is charity, and is running about as well as one can expect from charity -- income limits, minimal services, constant worry that someone might get something to which he's not entitled.

We are already on the way because of Obama's deficit

Good article in yesterday's NYT showing Obama's responsible for only ten percent of the deficit, even when his health care plan comes on line.

As I recall, 27% comes from the recession, and the rest is due to Bush's tax cut, Bush's war, Bush's prescription plan for Medicare, and Bush's bank bailout.

But the new law would mandate MD participation.

Coerced labor.No optioning out.

How can pogo know this when no one has seen a copy of the new health care plan? Most commenters here think we will have single payer, and have been marshalling their counterarguments appropriately.

Medicare and Medicaid isn't as bad overall, IMO, as the true government run health care plan - the VA hospital system

I'm never going to believe US News again, if that's true.

US News and World Report Rates VA Hospital Care - "Top-Notch"

July 12, 2005

In the July 18, 2005 issue of US News and World Report, VA hospital care is touted as often "the best around." The article attributes this high rating to the transformation of the VA health care system over the past decade. Beginning in the l990's under the leadership of Dr. Kenneth Kizer, the Veterans Health Administration instituted a performance and accountability system that was tied directly to the quality of patient care and outcomes

Sounds pretty good to me.

Should government take control of the medical industry, doctors will simply find another line of work.

Sure, last time I was in Canada I'm pretty sure that was an ex-radiologist slinging fries at Poutine World (Le Monde de Poutine).

doctors are business people.

I thought doctors are healers. Most doctors I know would rather not deal with the financial side of things. A friend's sister-in-law, with crushing debt from USC, works for Kaiser for a straight paycheck.

Kristof's column in the NYT today: "America's health care system spends nearly twice as much per person as Canada's, ... [for] 40% higher infant mortality rate, and a 57% higher rate of deaths in childbirth."

I also don't see the rationale for the profit motive in the provision of medical services..

Evidently Medicare doesn’t either as it’s destined for insolvency by 2018. It would be nice if the proponents of universal health care would let the rest of us know how we’re going to pay for 300 million US citizens (I’ll be naieve and assume the estimated 15 million illegal immigrants will not be covered). Current Medicare benefits paid out for 42 million beneficiaries comes to the tune of $450 billion. That’s just a tad shy of the current defense budget. Let’s say for the sake of argument that covering everyone will cost $1 trillion annually. Where does the money come from? Tax the ‘rich’? Ok go get em but do the math kids and you’ll find out that even at 90% marginal rates, that ain’t enough money. That means Obama’s promise for middle class tax cuts is a lie unless of course we borrow more, oops wait. Looks like the Chinese and Russians don’t want to borrow as much anymore so now what?

The only way to make it work is that everyone, I mean everyone, rich poor and middle class have to have some skin in the game and that means paying more taxes because there simply is not enough in the richest 1% to pay for it all.

The other aspect will be a massive curtailing of services as I described above which limits care to major medical coverage and you pay for your own general care because there simply won’t be enough money for all of it.

"In truth, most doctors in the field probably will fell little financial impact from a new national health plan, whatever it might turn out to be."

In truth, most auto dealers in the field will probably feel little impact from a new national auto company. Well, except the ones who are put out of business. But it's all for the greater good, and who knows more about that than The Gummint?

This is an assertion, although one that strikes me as probably true. However, inefficiency is relative. Is the United States' health care system inefficient, relative to... who?

I would like to see a list of which country's systems are considered more efficient. Then from there, we could look at what characteristics, positive and negative, go along with those efficiencies. I can easily imagine how there are attributes of an inefficient system that are so compelling as to make it preferable to an efficient system.

Then, any plan crafted should take into account not merely how to make things more efficient but also how to ensure that the good attributes do not get lost. Or, if by their very nature, they would be, then we the people would need to make a value choice between those attributes or efficiency.

"I also don't see the rationale for the profit motive in the provision of medical services"

Sigh. It's the oldest lesson in economics, but we have to learn it over and over and over. Adam Smith said it best: “Man has almost constant occasion for the help of his brethren, and it is in vain for him to expect it from their benevolence only. It is not from the benevolence of the butcher, the brewer, or the baker, that we can expect our dinner, but from their regard to their own interest.”

Enigmatic Core: very good question. The difficulty is, of course, defining "efficient." If we want to measure efficiency in terms of health care cost figures, it is probably most efficient to simply euthanize a patient when the prognosis is bad; especially after the patient is elderly. Euthanization can be done by an RN rather than a doc and with fairly inexpensive barbituates, and will save all kinds of money to delay what will be an evitable bad outcome (apologies to Johnathan Swift). I don't endorse that approach, but merely cite it to highlight the need to define efficiency.

I will submit your question cannot be answered until we explicate what values we want from a medical intervention (not simply efficiency as perhaps measured in terms of cost). I proposed one measure above: life expectancy following intervention--but even that can be expensive unless we start to talk about the value of life expectancy--and most people avoid that issue.

Really? I hadn't heard about that. I knew some Canadian doctors had come here so they could make the big bucks. What I've been reading lately is how Americans go to the Third World for health care:

Overseas, Under the Knife

ARNOLD MILSTEIN, MARK D. SMITH and JEROME P. KASSIRERPublished: June 9, 2009 ONE consequence of the high cost of medical care in the United States has been the rise of medical tourism. Every year, thousands of Americans undergo surgery in other countries because the allure of good care at half the price is too good to pass up.

Average total fees at well-regarded hospitals like Apollo and Wockhardt in India are 60 percent to 90 percent lower than those of the average American hospital, according to a 2007 study by the consulting group Mercer Health and Benefits

I'd fix Medicare by increasing the tax to 5%. It's about 2.9% today and raise the ceiling on incomes to a $5 Million lifetime ceiling. That means once yiu have made $5 Million, you are exempt from the Medicare tax.

I'd get rid of most all FICA taxes and fund social security benefits from income taxes and everyone has to pay some taxes.

I'd simplify soc security plan so everyone gets the same exact benefit amount at age 65 tax free. No early or delayed retirements. The benefit amount goes up as you get older. One or two actuaries could be employed to calculate benefit amounts.

I'd replace soc sec disability with a mandatory payroll type tax that would go towards a individual's purchase of a disability insurance policy and a life insurance policy when you first start working. It would cost no more than 0.5% or so of earnings. This would be universal and would enable the govt to fire everyone in the social security administration as well. We would not need them any more.

If I was Obama, I'd put off trying to give health care to everyone unil I fixed Medicare and Soc Sec.

fls said "The government is not planning to replace insurance companies, merely to provide one more option in the market place."

No, they will provide the only option. Your 'choice' of insurers will be completely controlled by the government. That's not a 'marketplace'.

"the July 18, 2005 issue of US News and World Report, VA hospital care is touted as often "the best around"

Right after that came the VAH scandals: revelations of corruption, From Huffpo"An in-depth journalistic investigation now suggests that the VA has been misleading policymakers and the public about its accomplishments for some time.

Deceptions about appointment wait times and patient satisfaction are wrong, and overstating the availability of PTSD treatment is reprehensible."

In nationalized UK care (NHS), they play similar games with data.That is, all of socialist data claims are suspect and probably bullshit.

If private insurers are pushed out of the market, the group said, "the corresponding surge in public plan participation would likely lead to an explosion of costs that would need to be absorbed by taxpayers."...

Doesn't the AMA actually mean a public plan would lead to an implosion of profits which will equate to a savings for the taxpayer?

My personal doctor, and his wife who is also and MD, moved to podunk Kentucky from Canada because they could make a much better living. They just happen to provide excellent healthcare to hundreds of people also.

Many of the doctors in podunk Kentucky moved there for this reason, a good living. How idiotic is it to expect a bright, intelligent person to spend many years in school and internships and not expect to make a good profit.

The long term effects of Obama's plan will be disasterous. Will the best cardiologist in our town, who grew up in India, one of 13 kids in a small house, move to the U.S., work his butt off to become a cardiologist just to make the same "profit" as a schlep computer programmer like me? I doubt it.

Of course, the rich, powerful politicos will all have plenty of medical treatment available to them since they're so much more important than the rest of us. Talk about greed, greed for power.

Where do you draw the line? Is it acceptable for a cable business to make 10% profit? How about the phone company? the NFL?

Why is it wrong that self-driven, motivated, hard-working, smart, talented doctors make a good profit? or a fair return on their investment in years of education?

You are the kind of person who sees no disparity in a tenured philosophy prof getting a salary of $100K or more plus great benefits and pension but you think a physician should not have an OPPORTUNITY to make far more money?

"Yeah Pogo, what we need is free market profit incentives to bring down the costs."

Do you actually think our current process represents a market??

Christ. The government already controls more than half of medical spending, more like 60%.

For lefties, the reason for out-of-control medical spending is that remaining 40%.

"The Centers for Medicare & Medicaid Services (CMS) estimated the 1999 government share of total US health spending as 45.2% ($548 billion). This estimate includes funding for Medicare, Medicaid, workers’ compensation, the Department of Veterans Affairs, public hospitals, and government public health activities.

Woolhandler and Himmelstein recently recalculated the government share of health expenditure by including these tax subsidies and public employee private health benefits, and concluded that the government-financed share of total health spending in 1999 was 59.8%, equal to $723.8 billion or $2604 per capita.

A 2000 study by Fox and Fronstin also concluded that the government share of expenditures on health care in 1998 was about 60%."

I completely agree that doctors like the idea of universal health care, in principle, I just think that when they actually see it they'll either go nuts or 'vote with their feet', as many have already done.

why did you post that silly snark when I specifically disavowed that approach in my post? Please have the intellectual honesty to disagree with my post on substantive grounds.

If you raise a ridiculous argument, expect a proportionate response. You can't expect a weaseling disclaimer like this: I don't endorse that approach, but merely cite it to highlight the need to define efficiency to save you.

That type of BS is one reason why I quit posting for 6 months--and will probably not waste any more time posting.

If raising and destroying ridiculous strawmen is your preferred commenting style, frankly I don't see the downside.

2) The very existence of medical insurance itself. If, instead of buying beer, I bought "beer insurance", and I showed my card at the grocery to get all the beer I could carry away, then the actual cost of beer (or, in my case, the cost of my beer insurance) would skyrocket -- because everyone would be carrying away pony kegs of beer on a daily basis. Insurance has created a disconnect between consumer and cost -- it's fueled excessive consumption and short-circuited the usually self-correcting mechanism of increased price with increased demand.

And I don't see how socializing this system will make it better. If the government essentially makes all medical care free (either directly or indirectly through government "insurance"), this could only increase demand. Prices will increase, unless they're controlled; and if prices are controlled, supply will dwindle (doctors will leave, or leave the profession), and we'll have waiting lists to get broken arms set.

Insurance has created a disconnect between consumer and cost -- it's fueled excessive consumption and short-circuited the usually self-correcting mechanism of increased price with increased demand..

Well that's exactly what I said way above. Ask yourself if you utilize your car insurance in the same manner as your health insurance. If you expected to pay only a $10 co-pay for every oil change, tire rotation, tune-up etc, your auto insurance would be unaffordable.

"The government is not planning to replace insurance companies, merely to provide one more option in the market place."

You really don't understand the free market place do you? When a cheaper alternative is offered to individuals AND to employers, they will opt for the cheaper alternative: nevermind that it doesn't provide anything near the original coverage and that it will absolutely be on a quota system for rationing care. The result will be that many will be forced to the Government system and those who can afford the "good" care will buy the more expensive insurance.

The result will be an even MORE class/wealth tiered system. Those who can afford it will get care, those who can't or who are forced to accept the government insurance won't get any choices.

"Medicaid is charity, and is running about as well as one can expect from charity -- "

I think you have a different definition of "charity" than the rest of the world. I'm not forced to pay taxes to support the Red Cross or the Salvation Army. I AM forced to pay taxes that then go to Meciaid or Medi-Cal in my State. Medicad is WELFARE. Tax payer supported welfare. And as such is rife with corruption, missuse and out and out fraud.

Hoosier -- so what's the long-term solution? Can we make regulations prohibiting insurance policies with absurdly low co-pays? Could we force all insurers to only offer plans that required consumers to pay some fixed percentage (say 10%) of their bill?

We've had input here from a doctor or two, and from at least one person in the insurance industry, but I'm viewing this from a different perspective: I run a small business. This morning, our agent told me that our renewal will cost 18% more this year than it did last year.

I'm trying to figure this out:

a) Why do we see 30%, 20%, 18%, etc., annual increases in premiums when the inflation rate is 4%?

b) Where am I supposed to find the money to cover this, when my customers expect me to increase my prices by no more than that 4% rate?

Here's another solution: Allow small businesses to cross state lines and find cheaper alternatives; and allow them to group together and get the bargaining clout that large businesses enjoy.

Enigmatic Core: very good question. The difficulty is, of course, defining "efficient." If we want to measure efficiency in terms of health care cost figures, it is probably most efficient to simply euthanize a patient when the prognosis is bad; especially after the patient is elderly. Euthanization can be done by an RN rather than a doc and with fairly inexpensive barbituates, and will save all kinds of money to delay what will be an evitable bad outcome (apologies to Johnathan Swift). I don't endorse that approach, but merely cite it to highlight the need to define efficiency.

Or, a friend of mine was involved in an accident (not her fault) six years ago, and had six disks in her spine wrecked. Three quickly ruptured, the other three herniated, two rupturing last summer, and the last one likely did recently. The most efficient solution would have been to fill her full of narcotics for the rest of her, shortened (due to the heavy does of narcotics) life. The second solution would have been to fuse the disks, and feed her full of less narcotics for the rest of her, slightly longer, life. But a lot of money was spent by her private insurance company, and she now has almost full movement in her neck, and pretty good movement in her back. And between the surgeries and her neurstimulator(s), the pain is mostly under control w/o the narcotics.

Was that efficient? No. Was it good? She and I think so. She paid her insurance, and then reaped the rewards for it.

The other thing that has to be kept in mind is that it is somewhere between very hard and impossible to truly determine efficiency in the medical field. People try to compare apples to apples, and invariably find that some oranges have been introduced. If one health care provider uses more and more expensive procedures, it is more likely that he has less healthy patient mix, as compared to the next guy, than that he is just more inefficient.

Hoosier -- so what's the long-term solution? Can we make regulations prohibiting insurance policies with absurdly low co-pays? Could we force all insurers to only offer plans that required consumers to pay some fixed percentage (say 10%) of their bill?.

The solution is changing the culture of how we deal with our health care. If we want health insurance then we need to treat it like insurance, that which covers the big ticket items, broken bones, debilitating diseases, those things we don’t expect to happen but know very well might. On the other hand your equivalent of a monthly oil change and tire rotation (annual physical, flu, cold, reoccurring sinus infection) you pay yourself or at the least the lion’s share of the cost.

Can we make regulations prohibiting insurance policies with absurdly low co-pays? .No because people want absurdly low co-pays and insurance companies design coverage to accommodate those wishes. The result is an underwriting adjustment to the policy that increases the premium to compensate. This also doesn’t count state mandated coverage that insurers must offer.

Could we force all insurers to only offer plans that required consumers to pay some fixed percentage (say 10%) of their bill?.

Many policies already have deductibles and a 10% to 20% (and sometimes higher) co-insurance provision although the co-insurance generally cap out at a fixed dollar amount referred to as total out of pocket or OOP. For example, you have a $100K surgery; 20% of $100K is $20K but your policy has a $5000 OOP which means after you have paid out $5000, the insurer pays the balance of $95K. Again it’s changing the culture. Another example: A few years back the High Deductible Health Plans were thought to be a way to control insurance costs. Your policy would have a large deductible, say $2K after which the insurer kicked in. The premiums were significantly lower and the idea was to put the premium savings in a Health Savings Account which was tax deferred and portable and could be used to pay for care. We barely were able to sell them to employer groups. Why? No one wanted a $2,000 deductible. People don’t want health insurance they want health coverage. Big difference.

Are the insurance companies saddened the government erased 60% of their cost? Or did they lobby the government to take care of the elderly because they were sucking up all the profits? Like they got the government to take over prescription drugs because it was sucking up the profit from the elderly' supplemental policies.

Maybe instead of letting the insurance industry cherry pick who they want to cover we can let a nonprofit single payer do the job. A single payer that gets the entire population to pay a premium--enjoys the gravy premiums from healthy individuals as well as the unhealthy.

One problem with the idea of the government entering the market here, and possibly competing with private insurers, is that their typical way of controlling costs is by price fixing - fixing their reimbursement rates, and right now, as Pogo pointed out, Medicare reimburses below cost. And, note that at least in some hospitals, it is worse than what he is facing. I talked to a CFO of a hospital recently, and he indicated that Medicare was reimbursing at 50% (and the CA system at 25%).

Right now, most of this is made up for by private insurers cross-subsidizing Medicare (etc.) patients. But what happens when the government share increases dramatically? The amount of cross-subsidization required of everyone else increases dramatically. And, that drives up private insurance costs, driving even more people to the government programs.

Someone asked above why their private insurance costs were going up so fast, and that is probably the biggest contributor, the leveraging effect of Medicare and other government payers cutting reimbursement rates while actual costs are climbing, necessitating more and more cross-subsidization.

Why shouldn't doctors, etc. be greedy? The quote from Friedman pretty much sums it up. But keep in mind that it is the possibility of earning a good, and maybe even a great, living that drives many into spending four years in medical school, and then serving a residency of up to maybe 8 years after that. Specialists are lucky to start their own practice in their early thirties, after school and training since they were maybe 5.

Why not go to law school instead? The top graduates of the top law schools earn slightly more as their starting pay at the biggest law firms than the median income for GPs. And, that is years younger than when the GPs get out of their residencies and start to be able to pay off their student loans. And, of course, the top lawyers make a lot more than the top doctors. (Before you think that it is all stacked in the lawyers' favor, keep in mind that the mean income for physicians is above that for attorneys).

Or, if you don't want to become a lawyer, and are good with figures, there are places in the finance/investment industry where the bonuses are (or at least were) far higher than any physician can earn from his labor.

Hoosier has a good fix on how to change things to benefit all, and make it affordable to small businesses.

Obamacare will kill small businesses, taxing them or fining them to cover their employees, but they will pay; it's required.

Proponents of Obamacare act as if changing the incentives will alter nothing. But you will no longer get really smart people to go into medicine and research, because the educational investment and delayed gratification won't be worth it at all.

Instead, you'll get a plethora of mid-level practitioners giving most of the care in brief 5-20 minute visits. Very few people will get referrals to specialists, because there will be very few of them to see. And those slots will be rationed by age and illness.

As in Canada and the UK, the wealthy and connected will be able to cut in line in front of all the little people.

Random stuff from onparkstreet, who is, herself, a doctor, and has been for about ten years as an attending at a couple teaching hospitals. So, I'm not sure my advice, or thoughts, would be as good as Ezra Klein or Matt Yglesias. Those are 'go to' guys for healthcare, JAC.

Haven't read the thread, and, yet, I still comment:

1. I don't belong to the AMA, and I bet about 50-60 % of docs don't either. Think herding cats.2. Docs are miserable in the unholy mix of public and private that we have, where we seem to have the worst of both the public and private systems, so, many think: single payer! Easier! Less paperwork! Less hassle!

I argue, be careful what you wish for. Things can always get worse. It is a possibility. Also, in school and stuff, they learn that single-payer is superior. They are grinds - it says something in their notes, must be true.

3. Mandates don't get rid of human nature. If evil doctors just want the current system because of the ca-ching, doesn't mean the ca-ching chasing will go away. It will just be ca-ching chasing by a different person or in a different way.

4. If it were such a slam dunk, a state would have done it successfully, already. Look at the problems MassCare is having. Which onparkstreet predicted when she was a junior attending at a certain hospital in a certain Mass town (*cough*Boston*cough)

5. The US has, like, what population compared to Britain, France, Canada? Size matters....an equivalent would be health care mandated through Brussels for all of the EU countries. Ahem. Size matters.

6. Born in India. Raised in the US. Been looking at cool concierge hospitals in cool Indian cities lately, online. Just cause. I love the US. WONDERFUL, BEAUTIFUL, GENEROUS COUNTRY. But. Just. Cause. Always have a plan B.

Hoosier Daddy said, A few years back the High Deductible Health Plans were thought to be a way to control insurance costs. Your policy would have a large deductible, say $2K after which the insurer kicked in. The premiums were significantly lower and the idea was to put the premium savings in a Health Savings Account which was tax deferred and portable and could be used to pay for care.

That's what I have and I like it. So far this year and last, my insurance company has paid for my mamogram and pap. Can't think of anything else. I paid in full for a couple of medications for me and the kids, paid in full for a couple of urgent care visits, a few visits to the dr. And I still come out ahead. Lower premiums, plus I sock away tax-free money to use for my medical expenses. I am getting about 30% more out of each dollar I spend from the HSA. (Corrections from mathematicians welcome.) Even after I talked about how much I saved with the high deductible plan, I'm not sure I convinced anyone else to try it. I have wondered how many of the employees at my company are using this plan.

Another way to improve health insurance is to uncouple our insurance from our jobs.

The state, fed and local govts spend about $1.5- $2 Trillion a year on social re-distribution programs [this does not include soc sec or medicare benefits].

We could take that money and give every adult a check each month for about $500-$700. Of course, we would have to also scrap all the current programs but everyone could spend their money on whatever they want.

Plus, an added bonus is it would end "empathy" as we know it and the Democratic party would be out of business.

Thank you for stating that and for the Brussels context. I keep reading about how wonderful the healthcare systems works in Sweden, Canada, the Netherlands whose populations individually are comparatively dinky and collectively are less than 20% the US.

Not to jinx it or anything, but notice how good a discussion this has been? Notice what is missing from these comments? See how interesting and civil a place this could be if that missing "factor" were authoritatively excluded from the comments?

I am reminded of a quote I read today on another blog:“You cannot legislate the poor into freedom by legislating the wealthy out of freedom. What one person receives without working for, another person must work for without receiving. The government cannot give to anybody anything that the government does not first take from somebody else. When half of the people get the idea that they do not have to work because the other half is going to take care of them, and when the other half gets the idea that it does no good to work because somebody else is going to get what they work for, that my dear friend, is about the end of any nation. You cannot multiply wealth by dividing it.”Dr. Adrian Rogers, 1931

What with all that our government, Republicans and Democrats are doing to our country I am very concerned. I can’t help but wonder how much freedom we actually have anymore. What with the will of the people continuing to be overturned by the courts and our representatives not listening to our voices.

Add to that the news that China and Russia and others are trying to move away from the dollar. May explain why gold and silver continue to rise. I just check the the widget http://www.learcapital.com/exactprice and gold is trading at $954.70 and silver is at $15.41. If all this health care stuff goes through I expect people will be going deeper into those precious metals to hedge against future health problems.

Nothing to see here folks. This will get jiffy jammed down the electorates throat thanks to President Erkle The Merry Marxist and his cadre of leftists buffoons. The real American public is to busy trying to fend off his nascent attacks on their pocketbooks while praying to the almighty that they might still have a job after his scamulous plan goes into full overdrive. Hey, while your at it your Emperial Highness, throw in cap and trade and give that living symbolism of a human rat, Henry Waxman a big pat on the bag.

Look, if these two pieces of fraud legislation go through, this country will really be finished. Because after the leftists get what they want, then they will start to fabricate other ways to separate you from your money and wisk even more control over your lives than ever before. They will get there wish to emulate this country's society and economic culture after Sweden.

Democrats are warning businesses, health care providers, hospitals and other stakeholders in the healthcare debate not to attend meetings with Republicans. According to aides working for Senator Max Baucus, stakeholders who express public opposition to Democratic plans will be excluded from future negotiations.

Chase said... "If you believe that insurance companies aren't doing a great job for you, what in God's name makes you think that government will do a better job?"

Because it does now. By far more efficient with lower overheads. What do you think? that insurance companies aren't full of waste? that they pay "in full"? simply not true.

if it were true all physicians would take all coverages but they don't as it costs them too much to comply with submissions and wait for payment. that is a nearly universal truth.

for those doctors who don't want to take government payment? then go find another job.

for all our spending our national health care is a disaster compared to the rest of the first world....from everything ranging from infant mortality to life expenctancy, we are a second world country.

get real. that is all Obama's saying. it kills our business, adds huge costs to each thing we make and consume, and those uninsured drive up our costs due to the services they are forced to seek (i.e. hospital emergency rooms where no one can be turned away).

This past week the story was about Bela Kosoian. Bela is a 38-year-old mother of two studying international law at UQAM. In speaking with her she told us that she had come out of the former Soviet Union to live free. That was in her thoughts all weekend. On Thursday last Bela had entered the Montmorency metro station in Laval. She was on the escalator when a transit guard told her to hold onto the handrail. She replied that she didn’t have three hands as she was searching for something in her handbag. The guard persisted. She asked to be left alone. The guard called over a police officer. He asked her for identification. She refused. He handcuffed her and took her to a holding room where she was not allowed to call a lawyer. After 20 minutes she was released with a $100 ticket for not holding the handrail and a $320 fine for obstructing justice. Nothing we could add here would be a more eloquent indictment of the state of our city than the bare facts. As Bela said, “Stalin may be dead, but Stalinism lives on.”

from hdhouse: "for those doctors who don't want to take government payment? then go find another job."

If you can say that, then why can't I say: if you can't afford insurance or pay for healthcare, then go find another job.

See how stupid that sounds?

Just because someone is a doctor doesn't mean they have to become slaves to their patients. They are people too, you know? They have their families, their mortgages, etc. to worry about just like.

Unlike you though, they also have to worry about paying back a massive debt, they have to worry about making decisions that could potentially mean life or death for their patients, and they work long hours. They don't deserve to get reimbursements lowered even more than they already have.

The golden age of medicine where doctors made bank was back in the 80s or so. Before making ignorant comments, think.